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PRIVATE ONSITE WASTE TREATMENT <br /> �Vin r; SYSTEMS County: Burnett <br /> k. <br /> ( POWTS) <br /> INSPECTION REPORT <br /> Safety and Buildings Division Address:L$458 O�a 3rj <br /> (ATTACH TO PERMIT) <br /> GENERAL INFORMATION Sanitary Permif.No:SA N — 2I ,27 <br /> Personal information you provide may be used for secoes[Privacy Law,s.15.04(1)(m <br /> Permit Holder's Name: ❑City Village ®,Town of: State Plan Transaction ID#: <br /> zwn �o e.y nd urpos p ak�O.Y\& -- <br /> Insp SM Elev. SM Description: Parcel Tax No: <br /> o o \n 1e.A man We, <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic Benchmark I)p , 3Z <br /> Dosing <br /> Aeration Bldg,Sewer 2. 4 0 9?HZ <br /> Holding W e,Se` 3000g St/HtInlet 1 3. 35 19G.92 <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG VENTTo ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding >)S — >3 0 Dist.Pipe <br /> PUMP]SIPHON INFORMATION N A Infiltrative <br /> Surface <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss Sys Head TDH Ft <br /> Forcemain L I Dia Dist.To Well Top of lid <br /> DISPERSAL CELL INFORMATION MA �C,\a:no, 4an tc <br /> DIMENSIONS JW L #of Cells Type of System Distribution Media Manufacturer, <br /> SETBACK OHWM of Nav ❑ Conv ❑ Aggregate <br /> INFORMATION P/L Bldg Well Waters ❑ IGP ❑ Chamber Model Number; <br /> ❑ AG ❑ EZFIow <br /> CELL TO ❑ Mound o Other <br /> DISTRIBUTION SYSTEM Sec, X Pressure Systems Only <br /> Header/Manifold Distribution Pipes I X Hole I Observation Pipes <br /> pac pacing es <br /> SOIL COVER no so*\ cove.r alr +;me, of ;ns cc.i;on <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑No <br /> ;OMMENTS: (Include code discrepancies, persons present,etc.) Elevations taken with <br /> Filter Manufacturer: NA <br /> � — Electrician: Model: <br /> (Field directive given to plumber that all electrich4ring wheX necessary to b pleted by electrician per WI Admin Code.) ❑Yes❑No <br /> 'Ian revision required?❑Yes No 17 1 I ? 7;,S <br /> Ise other side for additional information Date POVfTS I is Signature Certification Number <br />